- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.12 / $443.12 / $2,722.64
| Professional | | $443.12 | $443.12 | $2,722.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,710.87 / $6,710.87 / $6,710.87
| Professional | | $6,710.87 | $6,710.87 | $6,710.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.44 / $2,955.36 / $6,710.87
| Professional | | $486.44 | $2,955.36 | $6,710.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.44 / $2,955.36 / $6,710.87
| Professional | | $486.44 | $2,955.36 | $6,710.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,788.54 / $3,100.30 / $8,236.85
| Professional | | $2,788.54 | $3,100.30 | $8,236.85 |